Citation Nr: 21028033 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 18-07 317 DATE: May 10, 2021 REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for bilateral plantar fasciitis (also claimed as heel pain) is remanded. Entitlement to service connection for right ear hearing loss is remanded. Entitlement to service connection for a mental health disorder (claimed as anxiety and depression) is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1993 to December 1997. He also served in the Oregon Air National Guard from 1998 to 2014, when he was assigned to the Retired Reserve. The agency of original jurisdiction (AOJ) determined that the Veteran had qualifying service from December 1998 to September 1999, as well as multiple periods from 2001 to 2014 (April 2001, October 2003 to November 2003, and February 2004 to February 2014). See DD 214s and related orders; 38 U.S.C. § 101(21)-(24); 38 C.F.R. § 3.6. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision by the Department of Veterans Affairs (VA). A hearing was held before the undersigned Veterans Law Judge in February 2021. A transcript of the hearing is of record. On review, the Board finds that additional development is necessary prior to final adjudication of the Veteran's claims. Specifically, it appears that there may be outstanding VA and non-VA treatment records, as detailed in the directives below. Regarding the right shoulder and right ankle claims, the Veteran was provided VA examinations in February 2016 and October 2017 that focused on the opposing joints based on the AOJ's examination requests, without imaging studies for these claimed joints. He has contended that his current problems are related to in-service wear and tear over time, including playing softball. In addition, he has contended that he may have hurt his right shoulder at the time of an in-service December 2013 motor vehicle accident. See February 2021 Bd. Hrg. Tr. Although an April 2014 line of duty determination following investigation shows that the motor vehicle accident was deemed not in the line of duty due to own misconduct a December 2013 CT scan performed as part of the related treatment shows that the Veteran already had degenerative changes in the right shoulder at that time. Regarding the bilateral plantar fasciitis claim, the Veteran has not been provided a VA examination. He has contended that he was seen in service for extreme pain in his heels beginning around 2007 but did not receive actual treatment because there was nothing to be done other than changing shoe orthotics. He has indicated that the problem has become recurring, and he just rests his feet with flare-ups. See February 2021 Bd. Hrg. Tr. A February 2012 service treatment record shows that the Veteran reported extended, intermittent pain in the right heel. He was diagnosed with traumatic achilles tendonitis and instructed not to wear a boot for a month. He again reported heel pain for which he planned to seek VA compensation on the December 2013 report of medical assessment form completed in connection with his retirement physical. Regarding the right ear hearing loss claim, the AOJ has conceded in-service noise exposure. The Veteran was provided a VA examination in February 2016, but the examiner determined that he had normal hearing in the right ear with audiometric findings reflecting no right ear hearing loss for VA purposes under 38 C.F.R. § 3.385. Nevertheless, the Veteran testified that his hearing has gotten worse since that time. See May 2016 rating decision (granting service connection for left ear hearing loss based on that exposure); February 2021 Bd. Hrg. Tr. Regarding the mental health disorder claim, the Veteran has not been afforded a VA examination. He has contended that his current difficulties started after his mother passed away unexpectedly in 2009 while he was still on active duty, which led to personal problems thereafter; he has not sought treatment but is planning to now. He also testified that he now sometimes reflects on that time in his life, as well as his earlier in-service experiences as a hospital corpsman. See February 2021 Bd. Hrg. Tr. The service records confirm his duties as a hospital corpsman during his first period of service and also suggest that he may have been having difficulties that affected his work starting around 2009 to 2010. See, e.g., June 2009 to May 2010 enlisted performance report. Based on the foregoing, VA examinations and medical opinions are needed for the claims. The case is REMANDED for the following actions: 1. Request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed disorders. This should specifically include Drs. Gidden and Rush and for any treatment received for his right shoulder through the Veterans Choice Program. See February 2021 Bd. Hrg. Tr. at 11-13. After acquiring this information and obtaining any necessary authorization, obtain and associate these records with the claims file. The Veteran also reported receiving treatment at the Sky Lakes Medical Center emergency room for an in-service right ankle injury around 2010 during the hearing; however, the available service treatment records reflect treatment in 2012 starting at that facility for an injury as described to the already service-connected LEFT ankle. If the Veteran believes there was also such an injury to the right ankle, he may wish to provide or request VA attempt to obtain records from that facility. 2. Obtain VA treatment records dated from June 2017 to the present from the White City VA Medical Center and Klamath Falls outpatient clinic. 3. DO NOT SCHEDULE THE FOLLOWING UNTIL THE ABOVE VA AND PRIVATE RECORDS ARE OBTAINED TO THE EXTENT POSSIBLE. 4. After completing the foregoing development, schedule the Veteran for a VA examination to determine the nature and etiology of any current right shoulder, right ankle, and heel disorders that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. It is noted that the Veteran had qualifying service from March 1993 to December 1997 and December 1998 to September 1999, as well as multiple periods from 2001 to 2014 (April 2001, October 2003 to November 2003, and February 2004 to February 2014). (a) The examiner should identify all current right shoulder and right ankle disorders. For each diagnosis identified, the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to any period of the Veteran's qualifying service, including any symptomatology therein and the cumulative impact of his in-service duties. The Veteran has contended that his current problems are related to in-service wear and tear over time, including playing softball. In addition, he has contended that he may have hurt his right shoulder at the time of an in-service December 2013 motor vehicle accident. See February 2021 Bd. Hrg. Tr. Although an April 2014 line of duty determination following investigation shows that the motor vehicle accident was deemed not in the line of duty due to own misconduct, a December 2013 CT scan performed as part of the related treatment shows that the Veteran already had degenerative changes in the right shoulder at that time. (b) The examiner should state whether it is at least as likely as not that the Veteran has plantar fasciitis that manifested in or is otherwise related to any period of his qualifying service, including any symptomatology therein. The Veteran has contended that he was seen in service for extreme pain in his heels beginning around 2007 but did not receive actual treatment because there was nothing to be done other than changing shoe orthotics. He has indicated that the problem has become recurring, and he just rests his feet with flare-ups. See February 2021 Bd. Hrg. Tr. A February 2012 service treatment record shows that the Veteran reported extended, intermittent pain in the right heel. He was diagnosed with traumatic achilles tendonitis and instructed not to wear a boot for a month. He again reported heel pain for which he planned to seek VA compensation on the December 2013 report of medical assessment form completed in connection with his retirement physical. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 5. After completing the foregoing development, schedule the Veteran for a VA examination to determine the nature and etiology of any current right ear hearing loss that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. The examiner should state whether it is at least as likely as not that the Veteran has right ear hearing loss that manifested in or is otherwise related to any period of his qualifying service, including noise exposure therein. See also May 2016 rating decision (granting service connection for left ear hearing loss based on that exposure); February 2021 Bd. Hrg. Tr. (reported in-service duties). It is noted that the Veteran had qualifying service from March 1993 to December 1997 and December 1998 to September 1999, as well as multiple periods from 2001 to 2014 (April 2001, October 2003 to November 2003, and February 2004 to February 2014). A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 6. After completing the foregoing development, schedule the Veteran for a VA examination to determine the nature and etiology of any current mental health disorder that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment and personnel records, post-service medical records, and statements. The examiner should identify all current mental health disorders. For each diagnosis identified other than posttraumatic stress disorder (PTSD), the examiner should state whether it is at least as likely as not that the disorder manifested in or is otherwise related to any period of the Veteran's qualifying service, including any circumstances therein. With respect to PTSD, the AOJ should provide the examiner with a summary of any verified in-service stressors and instruct the examiner that only these events and any stressors related to fear of hostile military or terrorist activity may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. It is noted that the Veteran had qualifying service from March 1993 to December 1997 and December 1998 to September 1999, as well as multiple periods from 2001 to 2014 (April 2001, October 2003 to November 2003, and February 2004 to February 2014). The Veteran has contended that his current difficulties started after his mother passed away unexpectedly in 2009 while he was still on active duty, which led to personal problems thereafter; he has not sought treatment but is planning to now. He also testified that he now sometimes reflects on that time in his life, as well as his earlier in-service experiences as a hospital corpsman. See February 2021 Bd. Hrg. Tr. The service records confirm his duties as a hospital corpsman during his first period of service and also suggest that he may have been having difficulties that affected his work starting around 2009 to 2010. See, e.g., June 2009 to May 2010 enlisted performance report. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 7. Readjudicate the claims, including consideration of the additional service personnel records (some new) received since the December 2017 statement of the case. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Postek, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.